Basic Research—Technology
Apical Pressure and Extent of Irrigant Flow beyond
the Needle Tip during Positive-pressure Irrigation
in an In Vitro Root Canal Model
Ellen Park, DDS, MSc,*† Ya Shen, DDS, PhD,† Mehrzad Khakpour, PhD,‡
and Markus Haapasalo, DDS, PhD†
Abstract
Introduction: This study aimed to measure the pres-
sure generated during positive-pressure irrigation at
the periapex of an in vitro tooth model using a novel
method of measurement, investigating the effect of
flow rate and needle design. Apical pressure was corre-
lated with the extent of dye clearance from the end of
a needle tip in a plastic root canal model with similar
dimensions. Methods: The mesiobuccal canal of
a mandibular molar was instrumented to #35/06 and
placed into a chamber coupled to a pressure transducer.
Irrigation was performed using a digital peristaltic pump
using flow rates from 1–15 mL/min with irrigation nee-
dles of different sizes and designs. A plastic root canal
model instrumented to the same size filled with dye
was used to measure the extent of dye clearance beyond
the needle tip using the same irrigation conditions.
Results: Positive-pressure irrigation revealed a flow
rate–dependent increase in apical pressure (P < .05).
The apical pressure at high irrigation flow rates was
several times higher than at low flow rates. Needle
designs with safety features yielded statistically signifi-
cant lower apical pressures than needles without safety
features (P < .05). There was no further increase in
dye clearance from the end of the needle tip in a plastic
root canal model at flow rates higher than 4 mL/min.
Conclusions: If apical clearance of dye beyond the nee-
dle tip is a measure of irrigation effectiveness, then
maximum effectiveness with safe apical pressures
can be gained at specific flow rates using specific needle
tip designs. The use of an irrigation flow rate of 4 mL/min
was able to achieve maximum effectiveness in this
study. (J Endod 2013;39:511–515)
Key Words
Apical pressure, dye clearance, flow rate, irrigation,
needle design
From the *Private Practice, Vancouver, Canada; †Division of Endodontics, Department of Oral Biological and Medical Sciences, Faculty of Dentistry, The University of
British Columbia, Vancouver, Canada; and ‡Sonendo Inc, Laguna Hills, California.
Supported by the American Association of Endodontists and the Canadian Academy of Endodontics.
Address requests for reprints to Dr Markus Haapasalo, Division of Endodontics, Head, Oral Biological and Medical Sciences, UBC Faculty of Dentistry, 2199 Wesbrook
Mall, Vancouver, BC, Canada V6T 1Z3. E-mail address: markush@dentistry.ubc.ca
0099-2399/$ - see front matter
Copyright ª 2013 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2012.12.004
JOE — Volume 39, Number 4, April 2013
R oot canal irrigation plays an important role in the debridement and disinfection of
the root canal system and is an integral part of root canal preparation procedures
(1–4). Past research in endodontic irrigation has scrutinized the conditions under
which irrigants are able to reach the most apical portion of the root canal. Using
radiography, Salzgeber and Brilliant (5) concluded that an apical preparation size of
0.3 mm was required for irrigant penetration into the apical third, whereas Ram (6)
concluded that an apical size of 0.4 mm was required for this to occur. Further studies
suggested that in order for irrigation to be effective, the needle was required to be
placed close to the apical region, and a smaller-gauge needle was more effective
than a large-gauge needle (7, 8). When the comparative safety of various irrigation
methods was investigated, manual irrigation with a side-vented closed-end needle
placed at 2 mm from the working length resulted in periapical extrusion of the irrigant
(9). Current irrigation protocol recommendations suggest that clinicians should use
a small-gauge needle with a side-vented or closed-end design with the needle placed
in the apical third (10) or even 1 mm from the working length (11). There is no recom-
mendation for a safe and effective flow rate for endodontic irrigation, and apical extru-
sion of irrigants is an ongoing concern during positive-pressure irrigation.
Recently, 3-dimensional computational fluid dynamics (CFD) has been used
to simulate irrigant flow in a root canal model and evaluate parameters such as apical
pressure because of the force exerted by irrigant flow (12, 13). To our knowledge,
these simulated studies represent the first numeric estimation of apical pressure
during irrigation. Results are difficult to compare in this respect from 1 study to
another because different software algorithms and parameters such as irrigation flow
rate, apical size, and the taper of simulated models were used. One CFD study
reports an apical pressure of 1707 Pa (12.8 mm Hg) at 3 mm from the apex for
a beveled needle, whereas a side-vented closed-end needle resulted in 529 Pa (3.9
mm Hg) at 3 mm from the apex using an irrigation flow rate of 6 mL/min in a model
with an apical size of 0.4 mm and a 6% taper (14). A different CFD study using several
root canal model sizes and different irrigation flow rates reported a range of apical
pressures differing from the aforementioned study by several orders of magnitude
(15). CFD modeling also is able to generate streamlines, providing a visual represen-
tation of irrigant flow. One CFD study identified the limit of irrigant replacement beyond
the needle tip as 1–1.5 mm regardless of the range of flow rates used (12). Another
study compared the flow patterns generated in an in vitro root canal irrigation model
with the streamlines in an equivalent CFD model, with both models showing
good agreement (14).
Apical Pressure during Positive-pressure Irrigation 511
Basic Research—Technology
Presently, little is known about the range of apical pressures that
can be generated by different irrigation flow rates and different needle
tip designs. Previous studies on the effect of flow rate on the extent of
irrigant exchange in a root canal have not systematically studied a clin-
ically relevant range of irrigation flow rates. Together, there is limited
evidence for the recommendation of a safe yet effective irrigation flow
rate during root canal treatment. The aim of this study was to measure
the pressure generated at the periapex and the extent of dye clearance
from the end of a needle tip during positive-pressure irrigation, inves-
tigating the effect of flow rate and needle design.
Materials and Methods
Dye Clearance Measurement
A straight plastic root canal model with a closed apex (Dentsply
Tulsa Dental, Tulsa, OK) was prepared to apical size 35 (0.35 mm)
with a 6% taper (ProFile, Dentsply Tulsa Dental). A small, plastic cup-
like reservoir for the irrigant was affixed to the top of the plastic block
using an epoxy resin to act as a coronal chamber for the plastic root
canal. After instrumentation and careful removal of any plastic debris
within the prepared canal, crystal violet dye (BD Diagnostic Systems,
Sparks, MD) was used to fill the canal without air bubbles. The nee-
dles were attached by a Luer lock connection to 3-stop color-coded
Tygon ST tubing (Ismatec, Wertheim-Mondfeld, Germany). A digital
peristaltic pump (Reglo Digital MS-2/8, Ismatec) was used to deliver
the irrigant at precise flow rates. The peristaltic pump was calibrated
once at the start of the study with each irrigation needle to ensure
accurate flow rate by measuring the weight of water delivered through
the pump in a specified period of time and the range of reproducible
flow rates determined for each needle type. The needles were cali-
brated again with each set of irrigating conditions to ensure fidelity.
A microscope (Global Surgical, St Louis, MO) with a camcorder
device (1080p, HDR-XR520V; Sony, Tokyo, Japan) was used to
record each irrigation sequence.
The plastic block was irrigated at 5 and 3 mm from the
working length and, when possible without binding of the irrigation
needle, 1 mm from the working length. The canal was irrigated for
a minimum of 15 seconds at each flow rate and needle depth place-
ment using positive irrigation pressure. Each irrigation sequence was
repeated in triplicate. A still image at the 10-second time point from
each video was imported into ImageJ software (National Institute of
Health, Bethesda, MD) for measurement of the length of dye cleared
from the end of the irrigation needle; this was referred to as dye
clearance. The numeric data were imported into a spreadsheet,
and statistical analysis was performed.
Apical Pressure Measurement
An extracted human mandibular molar with 2 separate mesial
canals with independent apical foramina was chosen. The tooth was ac-
cessed, and size 08 K-files were placed in the mesiobuccal and mesio-
lingual canals to confirm separate canal systems by radiographic
examination and cone-beam computed tomography scanning with
a 0.076-mm isotropic voxel size. The mesiobuccal canal of this mandib-
ular molar was prepared to apical size 35 (0.35 mm) with a 6% taper
(ProFile) 1 mm short of the length at which an 08 K-file was seen under
magnification at the apical foramen. The size of the apical foramen was
adjusted to a 0.2-mm diameter. The mesiolingual canal was uninstru-
mented. Irrigation with approximately 10 mL 3% sodium hypochlorite
was used during instrumentation. Using a thin layer of nail varnish, the
main mesiolingual and distal apical foramina were sealed in order to
eliminate any effect of the presence of other foramina on apical pressure
measurements. The mesiobuccal apical foramen remained patent. The
512 Park et al.
tooth was placed into an air-tight custom fixture coupled to a piezoresis-
tive pressure transducer (8519B-5; Endevco, San Juan Capistrano, CA).
Incompressible silicone oil was used to separate the transducer from
water to prevent degradation of the transducer (Fig. 1). Pressure gener-
ated at the root apex during irrigation is transferred through the incom-
pressible fluid media to the pressure transducer. The setup allowed for
measuring pressures between 258 mm Hg and +258 mm Hg. Signals
were transferred to an oscilloscope (BK Precision, Yorba Linda, CA) via
a strain-gauge signal conditioner (Vishay, Shelton, CT), which was also
used to excite the pressure transducer. The oscilloscope sampled at 250
Hz (Fig. 1). The voltage readings were converted into pressure readings
using a conversion equation specific to the setup, which was verified
during calibration. Calibration was performed by inserting the tooth
into the pressure acquisition setup and internally pressured using
compressed air. The pressure applied in the tooth was adjusted using
a pressure regulator. Pressure increments of 1 pound per square
inch gauge (psig) starting from 0 psig (0 mm Hg) up to 5 psig (258
mm Hg) were selected, and the corresponding voltage outputs were
acquired. A linear fit of the pressure to voltage data resulted in the
conversion equation. The coefficient of determination value of the
voltage-to-pressure linear fit was R2 = 0.9993, which confirmed that
the pressure transducer was used within its linear response range. Irri-
gation was delivered as described in the previous section. The mesio-
buccal canal of the extracted mandibular molar was irrigated at 5
and 3 mm from the working length and, when possible without binding,
1 mm from the working length. The canal was irrigated for a minimum
of 10 seconds at each flow rate and needle depth placement using posi-
tive irrigation pressure. Each irrigation sequence was repeated in trip-
licate. The data from the oscilloscope were analyzed, and statistical
analysis was performed.
Irrigation Needles
Four irrigation needles were used: a 25-gauge blunt open-ended
needle with a flexible polyimide tubing tip (FlexiGlide; Vista Dental
Products, Racine, WI), a 30-gauge blunt open-ended needle with a flex-
ible polyimide tubing tip (FlexiGlide), a 30-gauge side-vented closed-
ended needle (ProRinse, Dentsply Tulsa Dental), and a 27-gauge slotted
Figure 1. An experimental design for pressure measurement at the apical
foramen. Different needle tip designs, flow rates, and distance from the apical
foramen were used in the measurements.
JOE — Volume 39, Number 4, April 2013

open-ended needle (Monoject 471 Endodontic Irrigation Needle;
Covidien, Mansfield, MA).
Statistical Analysis
Two-way analysis of variance (ANOVA) was used to determine the
presence of any interaction between flow rate and needle design on the
clearance of dye and apical pressure when comparing all or a selection
of needle designs. Two-way ANOVA also was used to determine the pres-
ence of any interaction between flow rate and the depth of needle place-
ment on the clearance of dye and apical pressure when examining 1
needle design at a time. If the interaction from any 2-way ANOVA analysis
was statistically significant, a post hoc Bonferroni test was used. Sub-
sequent 2-way ANOVA analyses were performed on subgroups of the
dataset in order to investigate conditions for interaction. The level of
statistical significance for the 2-way ANOVA and post hoc Bonferroni
analysis was set at a = 0.05.
Results
When measuring the clearance of dye beyond the end of the needle
tip at 3 mm from the working length, all 4 needles used showed a flow
rate–dependent increase in the length of dye cleared during irrigation
that plateaued at flow rates beyond 4 mL/min (Fig. 2). Two-way ANOVA
revealed significant interaction (P < .05), and Bonferroni post hoc tests
showed that the 30-gauage blunt open-ended (FlexiGlide) needle and
the 27-gauge slotted open-ended (Monoject) needle cleared signifi-
cantly more dye than the 25-gauge blunt open-ended needle (Flexi-
Glide) (P < .05) and the 30-gauge side-vented closed-ended
(ProRinse) needle. However, at flow rates beyond 4 mL/min, all of
the needles cleared between 2 and 3 mm of dye from the end of the
needle tip (Fig. 2).
Two-way ANOVA for data in the flow rate range of 1–4 ml/min
showed a significant interaction (P < .05), with needle design
comprising 61.51% of the total variance and flow rate comprising
29.24% of the total variance. Two-way ANOVA for data in the flow
rate range of 4–8 mL/min showed a significant interaction (P < .05),
with needle design comprising 91.85% of the total variance and flow
rate comprising 3.84% of the total variance. Flow rate was not a signif-
icant source of variation in the flow rate range from 4 to 8 mL/min
(P < .05).
Figure 2. Dye clearance during positive-pressure irrigation at 3 mm from the
apex. The bars show standard deviation.
JOE — Volume 39, Number 4, April 2013
Basic Research—Technology
All needles showed an increase in apical pressure as the flow
rate increased during positive-pressure irrigation (Figs. 3 and 4).
When the needles were placed at 3 mm from the working length,
the apical pressures ranged from 0.34 mm Hg (45.32 Pa) to
52.43 mm Hg (6690.09 Pa) (Fig. 3). Two-way ANOVA showed
a significant interaction (P < .05), with needle design comprising
34.25% of the total variance and flow rate comprising 44.98%
of the total variance. Post hoc Bonferroni analysis showed that
the mean apical pressures generated by the use of the 25-gauge
and 30-gauge blunt open-ended (FlexiGlide) needles were sig-
nificantly higher than those produced by all other needles
(P < .05).
When the needles were placed at 1 mm from the apex (Fig. 4), only
2 needles could be placed at this level in the root canal without binding
of the needle tip. These needles included the 30-gauge blunt open-
ended (FlexiGlide) needle and the 30-gauge side-vented closed-ended
(ProRinse) needle. The apical pressures ranged from 0.38 mm Hg
(50.66 Pa) to 87.26 mm Hg (11,633.71 Pa) (Fig. 4). A significant inter-
action (P < .05) was shown, with needle design comprising 21.33% of
the total variance and flow rate comprising 65.16% of the total variance.
Post hoc Bonferroni analysis showed statistically significant differences
(P < .05) between the apical pressures generated by these needles. The
needle that generated the highest apical pressures was the 30-gauge
blunt open-ended needle (Fig. 4). When the 30-gauge side-vented
closed-ended needle was placed at 1 mm from the working length,
the apical pressure was unpredictable and oscillated between low
and moderate apical pressures (Fig. 4).
Discussion
This study describes the first attempt to measure apical pressure
during root canal irrigation using an in vitro human tooth model.
This novel method is reproducible and represents a direct approach
to validating CFD estimations of apical pressure during irrigation; there
is potential to use this method to assess the safety of current and new
irrigating conditions and techniques. The parallel setup of the measure-
ment of apical pressure and dye clearance using similar root canal
Figure 3. Apical pressure during positive-pressure irrigation at 3 mm from
the apex. The bars show standard deviation.
Apical Pressure during Positive-pressure Irrigation 513
Basic Research—Technology
Figure 4. Apical pressure during positive-pressure irrigation at 1 mm from
the apex. The bars show standard deviation.
models allows the comparison of these 2 variables, representing
a measure of safety and effectiveness.
The measurement of the length of dye clearance beyond the end
of the irrigating needle tips used in this study revealed that in the clin-
ically relevant range of flow rates from 1 to 15 mL/min, there was
no further increase of clearance of dye at irrigation flow rates beyond
4 mL/min for all needle tip designs and sizes used during positive-
pressure irrigation. This was also shown by the use of 2-way ANOVA
on a subset of the data group from the flow rate range of 4–8 mL/min,
indicating that flow rate was not a significant source of the total vari-
ation in the data. The 2 needle tips that were able to clear the greatest
length of dye during positive-pressure irrigation were a 30-gauge
blunt open-ended needle tip and a 27-gauge slot-tipped needle.
Although both of these needles are equally effective in irrigant replen-
ishment in a canal, needles designed to vent the irrigant laterally
instead of apically may allow for increased patient safety. It is impor-
tant to consider that all of the needles used during positive-pressure
irrigation cleared a length of dye within a 1-mm range of each other;
should needles of varying sizes and designs have similar efficacy, then
a clinician should choose a smaller needle size and a needle design
that promotes lateral shunting of irrigant flow rather than directing
irrigant flow directly toward the apex of the tooth. Thus, in choosing
a needle design and size for root canal irrigation, a 27-gauge or 30-
gauge safe needle design can allow replenishment of the irrigant as
effectively as a 30-gauge blunt open-ended needle tip. A CFD study
compared two 30-gauge needles of different design and found that
a blunt open-ended needle tip design was able to fully replace irrigant
in a canal when placed 2 mm from the working length, whereas
a side-vented closed-ended needle tip needed to be placed at 1 mm
from the working length in order to fully clear the irrigant to the
apex (16). The current study also found similar trends with the
same needles. The 30-gauge blunt open-ended needle was able to
achieve almost 1 mm more dye clearance than the 30-gauge side-
vented closed-ended needle tip, but irrigation efficacy needs to be
514 Park et al.
balanced with patient safety considerations, and the absolute length
of irrigant replenishment cannot be the sole factor in choosing an irri-
gation needle tip.
The range of apical pressures generated during positive-pressure
irrigation in the current study shows good agreement with the range of
pressures calculated simulating irrigation at 6 mL/min using CFD anal-
ysis in a previous study (14). If the minimum and maximum apical
pressure measurement calculated in this CFD study is converted into
the pressure units used in the current study for a similar needle design
and size, the apical pressure range is similar. The CFD study range
would be 8–12 mm Hg in comparison to our range of 5–15 mm
Hg. Differences in the range of apical pressures calculated by other
CFD studies can be attributed to different experimental settings and
different turbulence models (16). It is not known exactly what pres-
sure requirements might result in a hypochlorite extrusion accident,
but it is interesting to consider that capillary pressure in the human
body is approximately 25 mm Hg in the capillary bed, 30–40 mm
Hg in the arterial end of the capillaries, and 10–15 mm Hg on the
venous end (17). Lymphatic capillary pressure, although often pre-
senting with a range of values, is generally lower than 10 mm Hg
(18). It is logical to assume that the periapical and pulp capillaries
at the venous end are a possible entry site of irrigant into the tissues
and that the apical pressure delivered by the irrigant should not
exceed that of the capillaries. The data of the present study show
that it is quite easy to exceed capillary pressure when the needle is
close to the working length even at low flow rates. The ‘‘safe’’ needle
design seems to confer an effective safety benefit. During positive-
pressure irrigation, the 25-gauge and 30-gauge blunt open-ended nee-
dles and larger-sized needles with design elements allowing lateral
shunting of the irrigant created significantly higher apical pressures
than other safe needle designs in smaller sizes. This seems to support
the overall effectiveness of the needle tips designed to enhance patient
safety. However, clinicians must still be cautious. When the smaller
needles were placed at 1 mm from the working length, both the blunt
open-ended needle tip and the side-vented closed-ended needle tip
created high and unpredictable apical pressures. It is not known
whether this unpredictability in apical pressure when this particular
needle is placed at 1 mm from the working length is a realistic repre-
sentation of what might happen in a clinical scenario. It is possible that
the unpredictable apical pressures could have been created by differ-
ences in positional placement of the needle. For instance, should the
side-venting portion of the needle have been partially blocked by
curvature in the root canal, this may have resulted in more apical
shunting of the irrigant. It is also possible that slight differences in
the depth of placement, such as a difference of 0.5 mm in the apical
placement of the needle caused by the investigator, may have caused
the unpredictable apical pressures.
The current study has limitations in its generalizability to all root
canals because this study used a single apical preparation size and taper
for the entire study. An apical preparation size of ISO 35 (0.35 mm) and
a 6% taper was chosen because this represents a common preparation
endpoint for many practitioners and enables the placement of certain
needles very close to the apical foramen. It should also be noted that
an extracted tooth model was used for apical pressure measurements,
whereas a plastic root canal block was used for the dye clearance
measurements. Thus, a comparison of results from these 2 experiments
should be performed with some caution. It may be useful for a future
study to use a cleared extracted tooth in similar dye clearance experi-
ments. However, chemical treatment of the tooth for making it trans-
parent may also alter the surface behavior of dentin and therefore
impact the results. Sources of error include challenges in maintaining
a system sealed against the leakage of air despite the use of adhesive
JOE — Volume 39, Number 4, April 2013

sealants to seal connections between irrigation needle tips and tubing.
There is also an inherent ebbing that exists in the delivery of irrigant
through a peristaltic pump. This was addressed by using a peristaltic
pump with multiple rollers in an attempt to achieve a smooth flow of
irrigant. The length and width of the vent in the various sizes of side-
vented closed-ended needles will also necessarily vary because of differ-
ences in the size of the needle barrel.
Considering the results of the 2 parts of the current study together
seems to be a step toward being able to provide a safe and effective
guideline for the irrigation of root canals. During positive-pressure irri-
gation, small-gauge safety irrigation needles have been shown to be
comparably effective to large- and small-gauge blunt open-ended irri-
gation needles in irrigant replenishment. When evaluating dye clearance
beyond the end of the needle tip during positive-pressure irrigation, it
was shown that at a flow rate of above 4 mL/min the dye clearance re-
mained unchanged. A strong increase in apical pressure above irriga-
tion flow rates of 4 mL/min was also shown with these needle tips.
Therefore, in order to avoid high apical pressures and gain the
maximum exchange of irrigant beyond the needle tip, one can use lower
irrigation flow rates with small-gauge needles using a safety design
without the concern of sacrificing irrigation effectiveness and poor
replenishment of irrigant.
The findings of this study and other studies may help to guide
researchers when designing future irrigation studies, especially with
respect to the depth of needle placement to ensure the exchange of
irrigant at the most apical portion and the influence of irrigation flow
rate on the extent of irrigant exchange. These are but 2 factors that influ-
ence irrigation efficacy; supplementary methods of irrigation may
contribute to address other factors. A recent study comparing a chlo-
rhexidine rinse or passive ultrasonic irrigation with sodium hypochlo-
rite as supplementary methods of irrigation showed no significant
difference between the 2 methods and that neither method could
predictably render the root canals free of bacteria (19). A separate
study comparing conventional positive-pressure irrigation, passive
ultrasonic irrigation, and continuous ultrasonic irrigation in their ability
to remove contrast solution from simulated lateral canals of extracted
teeth found that continuous ultrasonic irrigation significantly increased
the penetration of irrigant into lateral canals (20). It is increasingly
apparent that for irrigation to be fully effective, 1 approach might be
the combined use of several different supplemental techniques.
Future studies using this novel method of apical pressure
measurement should investigate the effect of apical preparation size
and canal taper on apical pressure and irrigant replenishment. Other
factors influencing apical pressure and irrigant replenishment such
as anastomoses between canals and severe canal curvature should
also be considered in future research.
In conclusion, all needle types included in the present study can
allow safe and effective irrigation. However, there are important differ-
ences in apical pressure between the needles depending on the flow rate
and the distance from the apical foramen, and it is important to be aware
of these differences. Based on the results of this study, there is no
JOE — Volume 39, Number 4, April 2013
Basic Research—Technology
requirement to irrigate at a very high flow rate, and a gentle irrigation
pressure yielding approximately 4 mL/min will achieve the maximum
length of irrigant exchange. This will allow clinicians to feel more confi-
dent when irrigating in the apical third of the root canal.
Acknowledgments
The author denies any conflicts of interest related to this study.
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Apical Pressure during Positive-pressure Irrigation 515